Melissa Mitchell, PharmD, BCPS, BCPP, BCGP, DPLA
Assistant Pharmacy Director
Riverside University Health System – Moreno Valley, CA
Dr. Cloyd is a graduate of the University of Texas at Austin with her bachelor’s in chemistry, followed by her PharmD from the University of the Pacific. She completed her PGY1 in Pharmacy Practice Residency at New York Harbor VA Medical Center in New York, NY before completing her PGY-2 Psychiatric Pharmacy Residency at VA San Diego. Following residency, she joined faculty of Long Island University in Brooklyn, New York. She joined Riverside University Health System Medical Center in 2010, as a Senior Clinical Pharmacist where she had the privilege of developing psychiatric pharmacy services. In addition, she created and was the residency program director for the RUHS PGY2 Psychiatric Pharmacy Residency until 2022. In her current role, she directs multiple teams, such as procurement, medication utilization, pharmacy compliance, managed care, and investigational drug services.
As a pharmacist starting a career in mental health or substance use disorder treatment, or one moving to another location, the court system and laws around mental health treatment and involuntary holds can feel overwhelming. Each state and county have their own laws and interpretation of the laws. Understanding the differences allows us to not only better serve our patients but also create avenues for advocacy.
For a patient in a mental health or substance use disorder crisis, their pathway to treatment can look very different depending on the state that they live in. No resources that allow someone to easily compare and contrast state laws regarding emergency involuntary holds exists. The Treatment Advocacy Center has graded each state on their psychiatric laws based on their policy recommendations and serves as a great resource but does not break down the states in a comparable fashion1. Hedman et al. compared state laws at the time (2014) in a concise format, but many of these have now changed or updated and vary significantly from state to state. For example, although all states allow a law officer to transfer someone to an evaluation facility, there is no consensus on who may initiate an emergency hold. In addition, the need for a judiciary review of the emergency hold, the length of the hold and the rights of the patient before and after the hold vary2.
The length of time for an involuntary hold can vary greatly both by state and county, but also by diagnosis (mental illness alone and/or with substance use disorder) or who is requesting the hold. For example, in California, a 5150 will hold a patient for 72 hours, while in Georgia, a 1013 certificate written by a mental health provider will allow for a 48-hour evaluation of a mentally ill patient with a high risk for harm to self or others. This can then be continued by a 1014 certificate for 5 business days and subsequently by a 1021 for 6 months of treatment3. In comparison, in Florida, family members, law enforcement, healthcare professionals or others can request a patient to be evaluated under a Baker Act or Marchman Act. A patient under the Baker act can be evaluated for 72 hours for a mental health crisis, while under the Marchman Act, can be evaluated for up to 5 days for substance use disorder4.
Many states have clear pathways to require treatment of patients currently being charged with nonviolent crimes awaiting trial. For example, a criminal detainee in Washington state who has been deemed unable to stand trial and refuses medications, or inadequately takes medication for a week or more, may be required to take medication under the Sell Hearing5. The need to require medication for a civilian patient is much harder to distinguish between the states. A Riese Hearing, or Capacity Hearing, is required for civilian psychiatric patients on an involuntary hold deemed to no longer have capacity to refuse medication in California. The Riese hearing removes the patient’s right to refuse medication for the duration of that legal hold (i.e. 14 days for a 5250) but does require an additional court date and hearing for any subsequent holds to extend the use of medications when refused6.
In addition to variances in legality for length of stay and treatment, there are differences in the duty to warn. The Tarasoff rule, or duty to warn, may be required when an identifiable victim in immediate harm6. For example, a patient stating they will kill their ex-neighbor with a gun, when they do not know where they live nor have access to a gun does not require a duty to warn. However, the opposite would be true if they did know the person’s whereabouts and had access to a firearm. The American Psychological Association recommends not only knowing what the recommendation is of the state you practice but also of recent court cases, and this is often seen as a controversial rule as it breaks the confidentiality of the patient and therapist7.
Each of these legal nuances can play a role in your treatment recommendations and goals for the patient. A shorter length of inpatient treatment stay may require the introduction of a long-acting injectable earlier in a patient’s stay than someone staying for a prolonged period. For those medications which have been court approved for a patient unable to refuse medications during a specific hold, it is crucial to ensure that no medication is approved nor dispensed once that hold has expired. Ensuring proper medication forms are available is key for those patients approved by the courts, which only becomes harder during ongoing drug shortages.
So where do you start to learn the “law of the land”? If you have a medical residency program for psychiatry, reach out to their Graduate Medical Education GME office to determine if you can sit in on the first-year residents’ review of these topics. Additionally, get to know your senior attendings, as well as the social worker(s), you will be working with. They have a plethora of knowledge to share and can often tell you about unique experiences in which they learned about laws in other areas that were even unknown to them. Take the time to review any documents your county puts out about patient rights, and when possible, review any changes to case law. All these resources will allow for a greater understanding of legal requirements in your county and state.
